Week 114: Pregnancy Flashcards
What is cardiotocography (CTG)?
Continuous electronic monitoring of the fetal heart and uterine activity
How is fetal heart rate monitored?
Using Doppler ultrasound
Where is the transducer placed when monitoring the fetal heart?
Over the anterior shoulder
What is a foetus’ heart rate controlled by
- Sympathetic system increases heart rate
- Parasympathetic decreases heart rate
- Maturity increases heart rate
- Also controlled by chemoreceptors and baroreceptors in the aortic arch
What is a normal fetal heart rate?
110-150bpm
What is the normal beat to beat variability in fetal heart rate?
5-15bpm
What checks occur post delivery?
- Apgar score
- Birthweight
- Body temperature
- Head circumference
- Pass of urine/meconium within 24 hours
What does the full neonatal exam consist of?
- Colour, breathing, behaviour, activity, posture, tone
- Head circumference
- Check fontanelles, palate, nose, ears, symmetry of head and facial features, assess eyes (red reflex)
- Limbs: proportions, symmetry, no. digits, congenital dislocation of hip
- CVS: HR, murmurs, arrhythmias
- Chest: auscultation, symmetry, signs of respiratory distress, respiratory rate
- Abdomen: assess or organomegaly, check umbilical cord insertion site
- Genitalia: exclude undescended testes in males
- Anus: exclude imperforate anus
- Spine: exclude spina bifida
- Note any birthmarks
What is labour?
Regular painful contractions in the presence of cervical change
What is the initial assessment of a woman in labour?
- Check temperature, pulse, BP, urinalysis
- Enquire regarding SROM (spontaneous rupture of membranes)
- Monitor contractions, check fetal heart rate
- Abdomen: presentation, lie, engagement
- Offer vaginal exam
What is a partogram?
Graphical record of the maternal and fetal observations over time
- Maternal vital signs
- Uterine activity
- Analgesia
- Medications
- Fluid balance
- Fetal heart rate
- Cervical dilatation
- Fetal presentation and position
- Station of presenting part
- Presence of liquor and colour
What is the attitude of the foetus?
The degree of flexion or extension of the head
What is the suboccipitobregmatic diameter?
9.5cm
What is optimal attitude?
So the suboccipitobregmatic diameter is presenting at the pelvic inlet
What is the lie?
The long axis of the foetus relative to the long axis of the uterus
- Longitudinal
- Transverse
- Oblique
What is presentation?
- Cephalic: longitudinal, occiput first
- Breech: feet first
What is the position?
- Left occiput-anterior -> Most common
- Left occiput-transverse
- Left occiput-posterior
- Right occiput-anterior
- Right occiput-transverse
- Right occiput-posterior
What is the station?
The leading bony edge of the presenting part relative to the ischial spines of the maternal pelvis
- If equal then 0
- Lower = +1/2/3…
- Above spines = -1/2/3…
Engaged at 0 and lower
When is the foetus engaged?
At 0 and lower
How many stages of labour are there?
3
What is the first stage of labour?
- The onset of labour to full cervical dilatation
- Divided into latent and active phase
What is the latent phase?
- The period between the onset of labour and a point at which a change in the slope rate of the cervical dilatation is noted
- Should be <20 hours
What is the active phase?
- Greater rate of cervical dilatation
- Begins around 3-4cm dilatation
- Cervix should dilate a minims of 1.2cm/hour
What is the second stage of labour?
- Commences when the cervix has reached full dilatation of 10cm
- Ends with delivery of the foetus
- Prolonged second stage is >3 hours
What is the third stage of labour?
- Delivery of the placenta and fetal membranes
- Usually <10 minutes
What are the cardinal movements of labour?
- Engagement
- Flexion
- Descent
- Internal rotation
- Extension
- External rotation
- Delivery of anterior shoulder (expulsion)
- Delivery of posterior shoulder (expulsion)
What are maternal indications for induction of labour at term?
- Preeclampsia/eclampsia
- Diabetes mellitus
- Chronic renal disease
- Chronic pulmonary disease
What are maternal contraindications for induction of labour at term?
- Active genital herpes
- Serious chronic medical conditions
What are fetal indications for induction of labour at term?
- Chorioamnionitis
- Abnormal antepartum testing
- Intrauterine growth restriction
- Post-term pregnancy (>42 weeks)
- Isoimmunisation
What are fetal contraindications for induction of labour at term?
- Malpresentation
- Fetal distress
What are uteroplacental indications for induction of labour?
Placental abruption
What are uteroplacental contraindications for induction of labour?
- Cord prolapse
- Placenta previa
- Vaso previa
- Prior ‘classical’ cesarean
What are hormonal techniques to ripen the cervix?
⇒ Prostaglandins:
- Dinoprostone (PGE2)
- Misoprostol (PGE1)
⇒ Oxytocin
What are hormonal techniques to initiate or augment uterine contractility?
⇒ Oxytocin
⇒ Prostaglandins:
- Dinprostone (PGE2)
- Misoprostol (PGE1)
What methods other than hormones can be used to ripen the cervix?
⇒ Amniotomy ⇒ Membrane stripping ⇒ Mechanical dilators - Hygroscopic dilators - Balloon catheter
What methods other than hormones can be used to initiate or augment uterine contractility?
Amniotomy
What types of pain relief are mainly used?
- Entonox (gas and air)
- Epidural
- Pudendal nerve block
What is the APGAR scoring system?
Airway Perfusion Grimace Activity Respiratory effort
For neonates
- Score of 2 for each section if normal
- Score of 0 for each section if absent
What are the two surgical delivery procedures?
- Forceps
- Vacuum
What are indications for surgical delivery?
- Maternal exhaustion
- Need to avoid maternal expulsive efforts
- Fetal stress
- Prolonged second stage of labour
What are indications for cesarean delivery?
⇒ Maternal - Failed induction of labour - Failure to progress (labour dystocia) - Cephalopelvic disproportion ⇒ Uteroplacental - Previous uterine surgery - Prior uterine rupture - Outlet obstruction (fibroids) - Placenta previa, large placental abruption ⇒ Fetal - Fetal distress - Cord prolapse - Fetal malpresentation (transverse lie)
What is the initial management of postpartum haemorrhage?
- Early recognition, monitor vital signs, O2
- Establish intravenous access, place urinary catheter
- Baseline laboratory values, alert anaesthesia, blood bank
- Correct hypovolaemia with crystalloid
- Central haemodynamic monitoring
- Correct anaemia/coagulation disorders
What are the pharmacological therapies for postpartum haemorrhage?
- Rapid oxytocin infusion (10-40 units/l)
- Methylergonovine (maximum 3 doses) [avoid in hypertension]
- 15-methyl-prostaglandin (Hemabate) (8 doses every 15-20 minutes) [avoid in asthma]
- Dinoprostone
What non-pharmacological management would be used in postpartum haemorrhage?
- Uterine packing
- Angiography and embolisation
- Explorative laparotomy with surgical options
What is the pharmacological management of preterm labour?
⇒ Calcium channel blockers - Nifedipine ⇒ β-adrenergic agonists - Terbutaline sulfate - Ritodrine hydrochloride ⇒ Oxytocin antagonists - Atosiban ⇒ Prostaglandin inhibitors - Indomethacin ⇒ Magnesium sulfate ⇒ Others - Nitroglycerine
When does the quadruple test panel occur?
15-20 weeks
What are the four markers the quadruple test panel uses?
- AFP
- β-hCG
- Inhibin A
- Estriol
When is an amniocentesis performed?
When a positive quadruple test panel comes back at 16-18 weeks
What is placenta praevia?
A placenta wholly or partly inserting into the lower segment
What is pre-eclampsia?
Proeinuric hypertension in pregnancy, developing after 20/40 weeks
